Otitis media is an infection with inflammation of the middle ear, common in infants and children under the age of 7, due to their immature immune systems and short, relatively horizontal, easily blocked eustachian tubes. Fluid may persist in the middle ear for weeks or months, causing at least some temporary hearing loss at an important time for language and cognitive development. Acute otitis media (AOM) is usually accompanied by a viral upper respiratory infection. Otitis media with effusion (OME) refers to the presence of fluid in the middle ear. It is generally asymptomatic and is often diagnosed during well-child examinations.

Blockage and swelling of eustachian tubes resulting from one or more of the causes listed below.

• Respiratory infection
• Allergies
• Tobacco smoke or other environmental irritants
• Infection and/or hypertrophy of the adenoids
• Sudden increase in pressure such as during an airplane descent
• Drinking while lying on the back
• Excess mucus and saliva produced during teething

The bacteria that cause most cases of acute otitis media are Streptococcus pneumoniae (25% to 35% of cases), Haemophilus influenzae (20% to 25%), Moraxella catarrhalis (10% to 15%), Strep. pyogenes—Group A (2% to 3%) and Staphylococcus aureus (1%). Some of the remaining cases are caused by viral infections. For OME, the most common causes are H. influenzae (15%), M. catarrhalis (10%), Strep. pneumoniae (7% and rising), and Staph. aureus (3%). Otitis media is not contagious in itself, but may be precipitated in multiple children by a contagious respiratory infection.

• Youth
• Male gender
• Winter
• Bottle feeding, especially lying on the back
• Pacifier use
• Group day care
• Allergies
• Exposure to tobacco smoke
• Sibling(s) prone to ear infections
• Enlarged adenoids or chronic sinusitis
• Native American or Inuit background
• Down syndrome
• Craniofacial anomalies
• Compromised immune system
• Children who have their first episode before 6 months of age are more likely to repeat

• Pain in the ear, usually worse at night; crying, irritability, disrupted sleep
• Feeling of "fullness," sometimes manifested in an infant as head-shaking
• Difficulty hearing
• Fever
• Vomiting and diarrhea
• Bulging eardrum

An episode of AOM may be followed by several weeks of OME.

• Otitis externa
• "Ear-pulling" due to itching or teething

Otoscopic examination reveals a red, opaque, bulging eardrum in AOM. Spontaneous perforation may occur. In OME, clear or yellow fluid may be seen through a translucent eardrum. A retracted eardrum (short arm of the malleus is prominent, long arm of the malleus appears shortened) indicates a partial vacuum in the eustachian tube, inhibiting drainage. Alternatively, an eardrum distended by fluid or fixed air pressure from a blocked eustachian tube obscures the malleus. Pneumatic otoscopy may reveal decreased mobility of the eardrum, indicating fluid or fixed air pressure in the middle ear.

Tympanocentesis (needle aspiration) may be employed to identify the bacteria involved in the infection, but this painful and invasive test should be done only when (1) the child is seriously ill or has not responded to standard antibiotic treatment and (2) precise identification of the disease-causing organism is essential.

Otomicroscope for detailed visualization if necessary. If AOM is complicated by mastoiditis, computed tomography (CT) should be used to detect intracranial complications such as epidural abscess.

Take patient history with special attention to recent respiratory infections or other causative factors. Examine eardrums using a pneumatic otoscope. Take temperature in both ears. A difference of more than 0.5º C is suggestive of AOM in the warmer ear.

A tympanometer (a soft rubber probe with an airtight seal) is placed in the ear canal, emits a sound, and measures its reflection, thus calculating the amount of the sound that is transmitted to the middle ear. This transmission is lower than normal in the fluid-filled ear.

An audiometer or other formal hearing test may be employed to discern any hearing loss, especially as a complication of chronic infection.

Many acute otitis media cases are self-limiting. However, delaying treatment requires follow-up visits for monitoring, and complications can be significant. Therefore, antibiotics are standard treatment.

AOM: First-line treatment is amoxicillin (Amoxil, 500 mg orally qid for 7 to 10 days), or azithromycin (Zithromax) if penicillin allergy is present. Second-line treatment is amoxicillin-clavulanate (Augmentin, 500 mg orally qid for 7 to 10 days) or cefuroxime axetil (Ceftin, 500 mg orally bid for 7 to 10 days). Parents should be reminded of the importance of completing the course. Combine with pain relief measures such as acetaminophen and/or ibuprofen.

OME: Begin with observation alone, or with antibiotics. Administer a hearing test if the condition is not resolved within 6 to 12 weeks. Guidelines advise treating with either antibiotics or myringotomy with tympanostomy tube insertion if fluid and a 20-dB hearing loss are present after 12 weeks. Tube insertion is recommended if OME is still present four to six months after initial diagnosis.

A large percentage of otitis media cases are self-limiting. Nutritional support, herbs, and homeopathic remedies are gentle ways to reduce recurrences and alleviate pain and acute infection.

Otitis media with effusion (OME) has a strong association with allergies. Suspect an allergic component if the child's first otitis occured before the age of 6 months, at or near the introduction of solid food or formula, or infections are recurrent and/or accompanied by eczema, asthma, or other atopic conditions. The following guidelines pertain to both AOM and OME unless otherwise indicated.

Eliminate all food allergens from the diet. The most common allergenic foods are dairy, soy, citrus, peanuts, wheat, fish, eggs, corn, and tomatoes. An elimination/challenge trial may be helpful in uncovering sensitivities. Remove suspected allergens from the diet for two weeks. Re-introduce foods at the rate of one food every three days. Watch for reactions which may include gastrointestinal upset, mood changes, flushing, and exacerbation of symptoms. A rotation diet, in which the same food is not eaten more than once every four days, may be helpful in recurrent OME.

Essential fatty acids are anti-inflammatory and support immune function. Children should be supplemented with cod liver oil or other fish oils (½ to 1 tsp./day). Vitamin C (100 to 250 mg bid to tid) enhances immunity and decreases inflammation. Vitamin C from rose hips or palmitate is citrus-free and hypoallergenic.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink two to four cups/day. Tinctures may be used singly or in combination as noted.

Herbal eardrops may be effective at reducing infection, pain, and fluid accumulation. Note: Eardrops are contraindicated if perforation of the tympanic membrane is suspected. An ear oil from mullein flower (Verbascum densiflorum) and garlic (Allium sativum) has pain reduction and antimicrobial effects. For otitis with pain, include one of the following oils: St. John's wort (Hypericum perforatum), Indian tobacco (Lobelia inflata), or monkshood (Aconitum napellus). Place 3 to 5 drops in ear bid to qid. Note that monkshood is toxic if taken internally.

Internal treatment should include one or more of the following:

• Coneflower (Echinacea angustifolia, purpurea, and pallida) may be taken as tincture or glycerite, 20 drops tid to qid. For chronic otitis, consider the following herbs that support the lymphatics and mucous membranes. Eyebright (Euphrasia officinalis), cleavers (Galium aparine), marigold (Calendula officinalis), and elderberry (Sambucus nigra) may be combined in a tea (2 to 4 oz. tid), tincture (10 to 20 drops tid), or glycerite (20 drops tid).

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve.

• Aconite for otitis that comes on suddenly after exposure to cold or wind; child has bright red ears and high fever
• Belladonna for sudden onset of otitis with great sensitivity and pain
• Chamomilla for otitis with intense irritability, especially with teething

A hot pack applied to ear and side of neck may relieve pain. Blanch one-half of an onion, wrap in cheesecloth, and apply hot to ear. The sulfur bonds in the onion will be soothing. May also use a hot water bottle or a sock filled with raw rice and heated.

Craniosacral therapy may be effective in enhancing lymph flow.

Gentle massaging of the neck may assist lymph flow.

Patient should return if AOM does not improve within 48 to 72 hours. Recheck within two to four weeks to ensure that infection has cleared and determine extent, if any, of effusion. Children with OME should be rechecked every four to six weeks until the fluid resolves, with special attention to detecting any retraction pocket ("pouch") in the eardrum that could lead to accumulation of dead skin cells (cholesteatoma). Tubes should be checked two to three weeks after insertion and every six months thereafter.

Reduction of environmental factors such as exposure to tobacco smoke and respiratory infections. Breast-feeding reduces incidence of AOM. Xylitol-sweetened chewing gum helps prevent ear infections by inhibiting Streptococcus. Prophylactic antibiotics may be prescribed for children who are particularly prone to otitis media. Adenoidectomy has a modest benefit in reducing the frequency of recurrent ear infections in patients for whom more conservative measures have not been successful. The S. pneumonia vaccine is becoming increasingly important, but current versions are not particularly effective before 2 years of age; a preparation effective in children as young as 3 months old is under investigation. The H. influenzae (HIB) vaccine does not protect against the "nontypeable" Haemophilus species that causes ear infections. Conservative introduction of solid foods as child is weaning may help prevent otitis and allergic conditions. If there is a strong family history of allergies or atopic conditions and/or if the child's immunity has been compromised in infancy, delay the introduction of highly allergenic foods until 1 year or older.

• Hearing loss, usually temporary
• Failure of perforation in eardrum to close, requiring repair
• Chronic purulent otitis media from external bacteria entering via perforation
• External eczematoid otitis, from drainage via perforation
• Facial paralysis from pressure on nerve
• Ossicular discontinuity, requiring surgical correction
• Cholesterol granuloma, requiring surgical removal
• Labyrinthitis, requiring early treatment to preserve hearing
• Mastoiditis
• Meningitis
• Brain abscess or empyema
• Cholesteatoma, a dangerous complication that can result in bone and tissue destruction

Serious complications have become less common with the use of antibiotics. However, physicians must be on guard for resistant organisms.

Symptoms of AOM should improve within 48 to 72 hours. It tends to resolve quickest in older children, during the summer, in mild cases, and in children without significant prior history of ear infections. OME that does not resolve within a few months with conservative treatment should be treated more aggressively.

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